Action Points

Note that this observational study of patients with a good initial response to medication withdrawal in the setting of medication-overuse migraines showed sustained efficacy at 9 years.

Be aware that some experts have intimated that withdrawal without prevention is unlikely to be successful.

The majority of patients with sustained chronic headache caused by medication overuse who had a good early outcome after withdrawal therapy had a good long-term prognosis that lasted for at least 9 years, a Norwegian study showed.

Even patients with a poor initial response to withdrawal therapy may improve with time, according to researchers.

The study revealed that in a cohort of 56 patients, the number with sustained chronic headache decreased from 27 (48%) at 1 year to 18 (32%) at 9 years (P=0.004) following withdrawal therapy.

The number of headache days per month also decreased over time, from 16.7 at 1 year to 13.3 at 9 years (P=0.007), Magne Geir Bøe, MD, PhD, of Sørlandet Hospital in Kristiansand, Norway, and colleagues said in an online report in Cephalalgia.

"Our study shows that the beneficial effect of withdrawal therapy on chronic headache persists over 9 years," the study authors wrote. "The majority (86%) of patients with an early response to withdrawal therapy (defined here as not having chronic headache 1 year after withdrawal) were still free of chronic headache at 9 years."

Previous studies have shown that medication withdrawal therapy leads to significant early improvement in about 28% of cases, the researchers noted. However, until now, follow-up studies have indicated that improvements can last for at least 5 years.

"It is totally useless to hospitalize and detox patients without first starting on a preventative regimen," said Stephen Silberstein, MD, director of the headache center at Jefferson University in Philadelphia.

Silberstein, who was not affiliated with the study, said that trials looking at the use of botulinum toxin type-A (Botox) and topiramate (Topamax) in patients with medication overuse headache have shown that patients who didn't undergo withdrawal therapy did just as well as those who did.

While she agreed that "patients should start up with prophylaxis before detox," Bøe added that in her experience, detox is often needed too.

"Medication withdrawal therapy should always be considered when treating patients with chronic migraine, and it is easier to perform than many doctors and patients fear," Bøe told MedPage Today. "The patient may benefit from the change in treatment strategy and experience how some of the migraine attacks improve without medication. This is my personal point of view after treating a lot of patients."

For the study, the researchers re-examined 56 of 80 patients who had participated in a medication withdrawal study with a 1-year follow-up between 2003 and 2007.

Data on headache, use of medication, quality of life, quality of sleep, anxiety, depression, and working outside the home were compared at 1 year after the start of withdrawal therapy and then again at 9 years.

In a subset of patients with a poor early response to withdrawal therapy and sustained chronic headache, long-term prognosis remained poor and most reverted to medication overuse within a short period of time, the study showed.

One year after withdrawal therapy, seven patients (13%) reported sustained chronic headache and medication overuse. After 9 years, this number had grown to 18 patients (32%).

On average, these patients experienced 25 headache days per month at 9 years and had a significantly lower vitality score than the rest of the cohort.

The study authors said they didn't know whether the improvements in headache and quality of life 1-9 years after withdrawal therapy were the result of withdrawal therapy or other factors.

"Why so many reverted to medication overuse, or whether some of them could have improved over time if they reduced their use of medication, is not clear," the researchers added, noting that the use of preventive drugs was low in this group. "Higher use could possibly have improved the situation."

The study also confirmed that a number of patients chose not to work after withdrawal therapy, with 61% collecting disability benefits at the end of 9 years compared with 38% 1 year after withdrawal therapy.

When medication withdrawal fails or there is little improvement in headache pattern, it is often very difficult to convince a patient to try again, noted Bøe. "We think that factors other than medication overuse may also contribute to headaches in this group and that we should make a greater effort to identify them rather than insist on repeated medication withdrawal attempts," she said.

Other studies have shown that patients who experience traumatic events in childhood have an increased risk of headaches and other co-morbid pain conditions later in life.

For Bøe, the 1-hour patient interview is key.

"I think one of the most important tools in treating these patients is a very careful interview about headache, other health issues, about social life, sleep pattern, and the patient's own understanding of the situation and how the patient thinks the headache should be treated."

It's important to be realistic about treatment, said Bøe. "I always tell the patients that I can teach them about how they can best take care of their headache and give advice about the best possible treatment. But I also tell them that they are responsible for their own progress, with my support and encouragement."

Limitations of the study include the small number of patients, possible bias due to the selection of patients with a favorable outcome, and the fact that muscle tension and previous traumatic events were not specifically examined.

The authors declared no outside sources of funding and no conflicts of interest.